Healthcare Provider Details

I. General information

NPI: 1013525120
Provider Name (Legal Business Name): DR. RENATO POPOVIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 01/06/2021
Certification Date: 01/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 CROSS COUNTRY DR
COLUMBUS GA
31906-1801
US

IV. Provider business mailing address

6635 BASS ROAD
FORT BENNING GA
31905
US

V. Phone/Fax

Practice location:
  • Phone: 706-568-7628
  • Fax:
Mailing address:
  • Phone: 800-214-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: